The IX t h Makassed Medical Congress - American University of Beirut

Recent trials examining the need for revascularization have concentrated on patients who could
be managed medically or with revascularization after a complete work-up including angiography.
The COURAGE trial and the BARI 2D trial both showed equivalence for medical therapy or
interventions. The question of percutaneous intervention or surgery as the revascularization
choice for patients who are judged to require it has been investigated in a number of trials
ranging from the EAST and BARI to SYNTAX. All of these trials, starting with balloon angioplasty and
moving to drug eluting stents, have shown relative equivalence of the two techniques for the
patients selected. Of most current interest is the longer-term follow-up of the SYNTAX trial which
investigated patients with extensive three-vessel disease and left main disease and which to date
shows no major difference in survival but an advantage for surgery in the avoidance of repeat
interventions. Most importantly, this trial demonstrated angiographic and clinical predictors of a
gradient of outcomes based on the extent of disease.
This is helpful in selecting patients; however, significant gaps still exist. Pertinent to the first question
(should revascularization be done?), the currently proposed trial, ISCHEMIA, will investigate
patients who have significantly more ischemia than those in the BARI 2D and COURAGE trials
and will randomize them prior to coronary arteriography to either continued medical therapy
or angiography with planned intervention. Pertinent to the second question, the group with
greatest survival differential favoring surgery, i.e. patients with diabetes, has been investigated in
the FREEDOM trial. This study of 1,900 patients completed enrollment in 2009 and will be the most
definitive comparison of diabetic patients undergoing drug eluting stenting or bypass surgery.
The advances in medical therapy, coronary intervention, and surgery have all made the outlook
for patients with stable ischemic heart disease much brighter than it was at the dawn of the
interventional cardiology era. Better understanding of the comparative effectiveness of these
approaches will help guide therapy in the future.
Mitral Regurgitation
TAVI WHERE DO WE STAND IN 2010?
Samir R. Kapadia, MD
E. Murat Tuzcu, MD
1. Mitral regurgitation (MR) is a significant problem, and the number of patients with MR is
growing with increase in patients with congestive heart failure. Surgical correction of MR with
repair techniques yields better results than valve replacement, however, a significant number
of patients undergo valve replacement even in the current era.
2. Various percutaneous approaches to mitral valve repair are under preclinical and clinical
investigation and show great promise for the future. These approaches are predominantly
based on established surgical strategies.
3. Different percutaneous techniques provide specific advantages depending on the
anatomical and functional characteristics of mitral regurgitation. Selection of the appropriate
technique/s for each individual patient will ultimately determine the success of these emerging
technologies.
4. Integration of established imaging modalities both in and out of the catheterization laboratory
is critical for safety and efficacy of percutaneous repair technologies. The development of
emerging imaging modalities will likely play a role in the future of percutaneous technologies.
5. Evaluation of new percutaneous devices poses a significant challenge because these
devices have to be compared to surgical options that may have different expectations in
the overall management of the patient. It is likely that percutaneous techniques will have a
complimentary role to surgery.
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